The present invention relates generally to methods and apparatus for treating eating disorders by application of modulating electrical signals to a selected cranial nerve, nerve branch or nerve bundle, and more particularly to techniques for treating patients with overeating disorders, especially obese patients, by application of such signals unilaterally or bilaterally to the patient""s vagus nerve with one or more neurostimulating devices.
Increasing prevalence of obesity is one of the most serious and widespread health problems facing the world community. It is estimated that, currently, about 6% of the total population of the United States is morbidly obese and a much larger percentage is either obese or significantly overweight. Morbid obesity is defined as having a body mass index of more than forty, or, as is more commonly understood, being more than one hundred pounds overweight for a person of average height. Aside from what may be an epidemic of obesity, it is believed by many health experts that obesity is one of the first two leading causes of preventable deaths in the United States, either ahead of or just behind cigarette smoking.
Whether or not that is an accurate assessment, studies have indicated that morbid obesity dramatically increases health care costs. It is a major cause of adult onset diabetes in the United States, up to approximately eighty percent of the cases. It may be a leading factor in as many as ninety percent of sleep apnea cases. Obesity is also a substantial risk factor for coronary artery disease, stroke, chronic venous abnormalities, numerous orthopedic problems and esophageal reflux disease. Researchers have documented a link between obesity, infertility and miscarriages, as well as post menopausal breast cancer.
The classical treatment option for obese people combines nutritional counseling with exercise and education, but has demonstrated relatively little long term success. Liquid diets and pharmaceutical agents can bring about acute, but not lasting weight loss. Surgical procedures for either gastric restriction or malabsorption in cases of severe obesity have shown the greatest success long-term, but are major surgery that can lead to emotional problems, and have their share of failures (e.g., Kriwanek, xe2x80x9cTherapeutic failures after gastric bypass operations for morbid obesity,xe2x80x9d Langenbecks Archiv. Fur Chirurgie, 38(2): 70-74, 1995).
U.S. Pat. No. 5,263,480 to J. Wernicke et al., assigned to the same assignee as the present application, discloses treatment for eating disorders including obesity and compulsive overeating disorder by selectively applying modulating electrical signals to the patient""s vagus nerve, preferably using an implanted neurostimulator. Modulating signals may be used to stimulate vagal activity to increase the flow of neural impulses up the nerve, or to inhibit vagal activity to block neural impulses from moving up the nerve, toward the brain, for producing excitatory or inhibitory neurotransmitter release.
Both of these cases of modulating the electrical activity of the vagus nerve have been termed vagus nerve stimulation, or VNS. The ""480 patent theorized that VNS could be used for appetite suppression by causing the patient to experience satiety, a sensation of xe2x80x9cfullnessxe2x80x9d of the stomach which would result in decreased food consumption and consequent weight reduction. For example, the stimulus generator of the neurostimulator is implanted in a convenient location in the patient""s body, attached to an electrical lead having a nerve electrode implanted on the vagus nerve or branch thereof in the esophageal region slightly above the stomach. If the patient""s food consumption over a given period exceeded a predetermined threshold level, detected and measured for example by sensing electrodes implanted at or near the esophagus, the stimulus generator is triggered to apply VNS and thereby induce satiety. Alternatively, VNS is applied periodically during the patient""s normal waking hours except in periods of prescribed mealtimes, or is applied as a result of patient intervention by manual activation of the stimulus generator using external magnet control. Patient intervention assumes a patient with an earnest desire to control his or her eating behavior, but normally lacking will power to control the compulsive behavior without the support of VNS.
Like most of the pairs of cranial nerves, the tenth cranial nerve, the vagus, originates from the brain stem. It passes through foramina of the skull to parts of the head, neck and trunk. The vagus is a mixed nerve, with both sensory and motor fibers, the sensory fibers being primary and attached to neuron cell bodies located outside the brain in ganglia groups, and the motor fibers attached to neuron cell bodies located within the gray matter of the brain. The vagus, as a cranial nerve, is part of the peripheral nervous system or PNS whose nerves branch out from the central nervous system (CNS) to connect the CNS to other body parts. Somatic fibers of the cranial nerves are involved in conscious activities and connect the CNS to the skin and skeletal muscles, while autonomic fibers of these nerves are involved in unconscious activities and connect the CNS to the visceral organs such as the heart, lungs, stomach, liver, pancreas, spleen, and intestines.
The motor fibers of the vagus nerve transmit impulses to the muscles associated with speech and swallowing, the heart, and smooth muscles of the visceral organs of the thorax and abdomen. In contrast, its sensory fibers transmit impulses from the pharynx, larynx, esophagus and visceral organs of the thorax and abdomen. The vagus is split into left and right branches, or left and right vagi, which run respectively through the left and right sides of the neck and trunk. It is the axial portion of the body, which includes the head, neck and trunk with which we are primarily concerned in respect of the present invention. The ventral cavity of the axial portion contains visceral organs and includes the thoracic cavity and the abdominopelvic cavity, which are separated by the diaphragm, a broad thin muscle. Visceral organs in the thoracic cavity include the right and left lungs, the heart, the esophagus, the trachea and the the thymus gland. Below the diaphragm, in the abdominopelvic cavity and specifically the upper abdominal portion or abdominal portion, the visceral organs therein include the stomach, liver, spleen, gall bladder, and majority of the small and large intestines.
The vagus nerve is the dominant nerve of the gastrointestinal (GI) tract, the right and left branches or nerve afferents of the vagus connecting the GI tract to the brain. After leaving the spinal cord, the vagal afferents transport information regarding that tract to the brain. In the lower part of the chest, the left vagus rotates, becomes the anterior vagus, and innervates the stomach. The right vagus rotates to become the posterior vagus, which branches into the celiac division and innervates the duodenum and proximal intestinal tract.
The exact mechanisms leading an individual to satiety are not fully known, but a substantial amount of information has been accumulated. Satiety signals include the stretch of mechanoreceptors, and the stimulation of certain chemosensors (e.g., xe2x80x9cA Protective Role for Vagal Afferents: An Hypothesis,xe2x80x9d Neuroanatomy and Physiology of Abdominal Vagal Afferents, Chapter 12, CRC Press, 1992). These signals are transported to the brain by the nervous system or endocrine factors such as gut peptides (e.g., xe2x80x9cExternal Sensory Events and the Control of the Gastrointestinal Tract: An Introduction,xe2x80x9d id. at Chapter 5). It has been demonstrated that direct infusion of maltose and oleic acid into the duodenum of rats leads to a reduction in food intake, and that the response is ablated by vagotomy or injection of capsaicin, which destroys vagal afferents. Introduction of systemic cholecystokinin also reduces intake in rats, and is ablated by destruction of vagal afferents.
While the vagus is often considered to be a motor nerve which also carries secretory signals, 80% of the nerve is sensory consisting of afferent fibers (e.g., Grundy et al., xe2x80x9cSensory afferents from the gastrointestinal tract,xe2x80x9d Handbook of Physiology, Sec. 6, S.G., Ed., American Physiology Society, Bethesda, Md., 1989, Chapter 10).
The aforementioned ""396 application discloses a method of treating patients for obesity by bilateral stimulation of the patient""s vagus nerve (i.e., bilateral VNS) in which a stimulating electrical signal is applied to one or both branches of the vagus. The parameters of the signal are predetermined to induce weight loss of the patient. The signal is preferably a pulse signal applied at a set duty cycle (i.e., its on and off times) intermittently to both vagi. In any event, VNS is applied at a supra-diaphragmatic position (i.e., above the diaphragm) in the ventral cavity. The electrical pulse stimuli are set at a current magnitude below the retching level of the patient (e.g., not exceeding about 6 milliamperes (mA), to avoid patient nausea) in alternating periods of continuous application and no application. Pulse width is set at or below 500 microseconds (xcexcs), and pulse repetition frequency at about 20-30 Hz. The on/off duty cycle (i.e., first period/second period of the alternating periods) is programmed to a ratio of about 1:1.8. The neurostimulator, which may be a single device or a pair of devices, is implanted and electrically coupled to lead(s) having nerve electrodes implanted on the right and left branches of the vagus.
According to the present invention, a method of treating patients for obesity comprises unilateral or bilateral stimulation of the left and right vagi at a sub-diaphragmatic position (i.e., below the diaphragm) in the ventral cavity, rather than at a supra-diaphragmatic position as taught by the ""396 application. The stimulating electrical signal is preferably applied to the vagus two to three inches below the diaphragm, and may be applied either synchronously or asynchronously to both the right and left branches, preferably in the form of a series of pulses applied intermittently to both branches according to a predetermined on/off duty cycle. The intermittent application is preferably chronic, rather than acute. However, continuous application or acute application by bilateral stimulation of the right and left vagi or unilateral stimulation of either branch, at the sub-diaphragmatic position, is also contemplated.
The sub-diaphragmatic application of VNS may have an enhanced effect in inducing satiety in the patient, being in closer proximity to the stomach itself. Certainly, in the case of neurostimulator device implantation superficially in the abdominal region of the patient, the sub-diaphragmatic application has an advantage of enabling shorter leads for the nerve electrode(s). Additionally, application of the neurostimulator may be more easily accomplished with this approach as opposed to a supra-diaphragmatic approach which requires accessing the vagi in the chest cavity.
Acute application of the stimulating electrical signal to the right and left vagi during a customary mealtime, or from a short time preceding and/or following the mealtime, according to the patient""s circadian cycle, may be effective in certain cases. Automatic delivery of bilateral intermittent stimulation is preferred, but it is alternatively possible to control application of the stimulating electrical signal to the right and left vagi by an external commencement signal produced by the patient""s placement of an external magnet, or by another patient-applied signal, in proximity to the location of the implanted device.
Preferably, the same stimulating electrical signal is applied to both the right and left vagi, but as an alternative, a stimulating electrical signal might be applied to the right vagus which is different from the stimulating electrical signal applied to the left vagus. And although two separate nerve stimulator generators may be implanted for stimulating the left and right vagi, respectively, as an alternative a single nerve stimulator generator may be implanted for bilateral stimulation if the same signal is to be applied to both the left and right branches of the vagus nerve, whether delivered synchronously or asynchronously to the vagi.
As with the method disclosed in the ""396 application, the current magnitude of the stimulating signal is programmed to be less than about 6 mA, and in any case is held below the retching level of the patient as determined by the implanting physician at the time the implant procedure is performed, or shortly thereafter. This is important to avoid patient nausea during periods of vagus nerve stimulation. Preferably, the pulse width is set to a value not exceeding about 500 xcexcs, the pulse repetition frequency is set at about 20-30 Hertz (Hz), the VNS regimen follows alternating periods of stimulation and no stimulation, with the second period about 1.8 times the length of the first period in the alternating sequence (i.e., the on/off duty cycle is 1:1.8).
The apparatus of the present invention for treating obese patients suffering from eating disorders includes an implanted neurostimulator for simultaneously stimulating left and right branches of the patient""s vagus nerve via separate lead/electrodes operatively coupled to the neurostimulator and implanted on the right and left vagi in a sub-diaphragmatic position, the stimulation being applied continuously during a first period, alternating with no stimulation during a second period, throughout the prescribed duration of the stimulation regimen.
Accordingly, it is a principal objective of the present invention to provide methods and apparatus for treating and controlling the overeating disorder, especially in obese patients, by means of bilateral electrical stimulation of the patient""s right and left vagi at a sub-diaphragmatic location.
Another aim of the invention is to provide methods of treating and controlling compulsive overeating and obesity by bilateral intermittent electrical pulse stimulation of right and left vagi at a sub-diaphragmatic position in the patient.
Alternative techniques include indirect stimulation of the vagus, either bilaterally or unilaterally, at a location near one or both branches of the nerve or elsewhere, which has the effect of stimulating the vagus nerve as well. This may be accomplished through afferents or efferents, for example.
It is also contemplated that direct or indirect unilateral or bilateral stimulation applied at or by way of a sub-diaphragmatic location of one or more of the other cranial nerves of suitable sensory, motor or mixed fiber types may be effective in treating compulsive overeating disorder, as an alternative to vagus nerve stimulation.
Some differences may be observed from stimulator to stimulator in magnitude of current in the pulses of the stimulation signal, and may be attributable to things such as patient impedance, variation of the vagus nerve from right to left or between patients, and variation in contact between the vagus and the electrode implanted thereon from implant to implant.
According to other aspects of treatment by stimulation of the vagus or other suitable cranial nerve in the vicinity of the patient""s diaphragm, beneficial weight reduction is aided by increased activity attributable to release of norepinephrine, serotonin or other mechanisms, increased metabolism and change in gastric motility. This therapy may also have beneficial effect in treatment of other disorders such as type II diabetes, high blood pressure and orthopedic problems which typically co-exist with compulsive overeating disorder and obesity.